Services Requiring Prior Authorization – Oregon/Washington
Please confirm the member's plan and group before choosing from the list below.
Providers should refer to the member's Evidence of Coverage (EOC) or Certificate of Insurance (COI) to determine exclusions, limitations and benefit maximums that may apply to a particular procedure, medication, service, or supply.
Refer to the Pharmacy section of the website for information regarding prescription authorization requirements.
Medicare providers: Use our tool to see if a pre-authorization is needed. It's quick and easy. If an authorization is needed, you can log into the secure provider portal below and submit it there.
Commercial providers: Visit the Commercial Pre-Auth webpage.
IMPORTANT INFO FOR WELLCARE/MEDICARE PROVIDERS:
Peer-to-Peer Review Requests
- Peer-to-peer review requests will be allowed up to two (2) business days after Integrated Denial Notice or day of discharge, whichever is later.
- Peer-to-peer outreach will be completed within 2 business days of peer-to-peer review request.
- If provider is not reached, a voice mail will be left (if possible) giving provider one business day to respond.
- If the provider does not respond within the stipulated timeframe, Wellcare will be unable to proceed with peer-to-peer request.
- No changes are being made to existing peer-to-peer timeframes or processes for pre-service requests.
Elective Medical Inpatient Authorization Process
- The prior authorization span for elective inpatient admissions will be increased to 60 (sixty) days for dates of service on or after 11/1/2022.
- If the planned admission date exceeds the authorized date span of 60 days, a new authorization span is required.
- Elective Inpatient Prior Authorization numbers will now start with the prefix of OP instead of IP.
- Notification of admission is required within one (1) business day of admit. At the time of admission notification, a new authorization number for the admission will be provided with the IP prefix. Failure to provide timely notification may result in a denial of payment.
As a reminder, all planned/elective admissions to the inpatient setting require prior authorization. Prior authorization should be requested at least five (5) days before the scheduled service delivery date or as soon as need for service is identified. If prior authorization is not on file at the time of elective admission, the service is considered retrospective and provider should follow the appropriate retrospective request process as communicated in the provider notice. Emergent admissions do not require prior authorization.
If you are a contracted Health Net provider, you can register now. If you are a non-contracted provider, you will be able to register after you submit your first claim.
Once you have created an account, you can use the Health Net provider portal to:
- Verify member eligibility
- Manage claims
- Manage authorizations
- View patient list